Exam 1- learning objectives Flashcards
Review the anatomy and physiology of the skin and mucous membrane.
Epidermis -outer layer-protection
Dermis-,middle layer-support/protection
Subcutaneous layer- insulation, supports, energy storage
mM-lubricates and protects organ cavities from invasive pathogens
Identify risk factors which contribute to impaired skin integrity.
Age
* Lifestyle variables
* Changes in health state
* Illness
* Diagnostic measures
* Therapeutic measures
Describe the system for staging pressure ulcers.
1-looks/feels red and warm.might burn hurt/itch.Erythma
2-partial thickness skin loss-skin starts to peel off
3-crater like appearance due o damage below surface-full thickness skin loss into dermis but not muscle or bone
4-The area is severely damaged and a large wound is present. Muscles, tendons, bones, and joints can be involved
Review phases of wound healing.
Homeostasis-Stop bleeding- vasoconrticiton to block drainage-
inflammation-veins dilate again, causing neutrophils to enter/destroy bacteria, brings wbc to area to kill off infection
proliferation-fill wound-granulation tissue is present, new bv are formed, rebuilding the old tissue
remodeling-the new tissue slowly gains strength and flexibility. Here, collagen fibers reorganize, the tissue remodels and matures and there is an overall increase in tensile strength
Differentiate between the different types of wound drainage.
Serous-white serum
serosanguineous- serum and blood
Sanguineous-blood
purulent-pus
Describe potential complications of wound healing.
Dehiscence-Partial or total
separation of wound
layers
Evisceration-Protrusion of viscera (internal
organs) through incision-organ protrudes out
Indicate factors affecting wound healing.
- Desiccation
- Maceration
- Pressure
- Trauma
- Edema
- Infection
- Excessive bleeding
- Necrosis
- Biofilm
- Age
- Circulation / Oxygenation
- Nutritional Status
- Wound Etiology
- Medications
- Immunosuppression
Summarize the factors that are components of the Braden Scale for Predicting Pressure Sore Risk.
Sensory Perception-LOC
* Moisture-skins exposure to moistue
* Activity-how often the move out of bed
* Mobility-ability to change position
* Nutrition
* Friction and Shear
Describe nursing interventions that will prevent skin breakdown and support wound healing.
Drains
wound dressings-protect wound
removing debris
provide moist wound healing envirment
proper nutrition
Identify risk factors for acquiring an infection.
Age
poor nutrition
stress
no sleep
disease
medical history
Review the chain of infection.
Pathogen-bacteria
resevior-where the pathogen lives
portal of exit-where exits body
mode of transmission-direct/indirect contact/vector
portal of entry-where enters body
susceptible host- anyone who will harbor disease
Outline nursing assessments for identifying an infectious process.
Fever
pain/tenderness
redness/swelling
tachycardia/penia
malaise-dsiconfort
WBC count
List interventions that break the chain of infection.
hand hygeine
vaccinations
covering coughs/sneezes
standard precations
contact isolation
ppe
cleaning/disinfecting equipment
Describe isolation precautions outlined by the CDC.
contact-gloves and gown-is contact with body secretions, make and eyewear
droplet-within 3-6feet,use standard precations and use mask
airborne-every time, gown gloves and n95 mask
blood borne-gloves,mask,eyewear,gown
Identify physical and psychological effects of the infectious process.
fever, headache, dizziness, rash, inflammatory response
delirium, mood disorder ,generally a worsened mood is a result of an infection
